Taking antidepressants is as risky as taking recreational drugs
Experts like Joanna Moncrieff view this with great concern. In an interview, the professor of critical and social psychiatry from University College London explains why this is so:
Dear Joanna! In your current study , you conclude that the dogma that depression is caused by decreased serotonin activity or levels is unfounded – and that this finding ” sent shockwaves through the general public.” How so?
Joanna Moncrieff : People believed there was scientific evidence linking serotonin and depression. And people believed that because in the 1990’s the pharmaceutical industry launched a very broad and very expensive advertising campaign. Their goal was to convince people that depression was caused by a chemical imbalance, and specifically a lack of serotonin, and that taking an antidepressant could fix it. This was a huge marketing campaign, targeting both doctors and the general public via the Internet.
In countries where direct-to-consumer advertising is possible, antidepressants have been advertised on television, radio and other media. That was very successful. This campaign was designed to counteract the common sense that actually tells you that taking a drug to solve an emotional problem is probably not a good idea. And indeed, what has been achieved with this campaign is that this notion is reversed and replaced with the belief that depression is a proven chemical problem. This is not the case. And it turns out there’s no evidence to support that belief.
Your criticism is actually not new. Psychiatrists like David Healy or Peter Breggin voiced exactly this criticism years ago. So why doesn’t this criticism surface to the surface of reality?
Leading psychiatrists have long known that there is no evidence to support the serotonin theory of depression. But nobody informed the general public about it. No leading psychiatrist has taken it upon himself to tell the public about it. People like David Healy have done that, and people like me and a few others have written about it. But leading psychiatrists, we have to conclude, are not concerned with continuing to mislead the public into believing that there is a link between serotonin and depression.
But they also face opposition. Ronald W. Pies, for example, Professor Emeritus of Psychiatry, replies to your review that “Historically, psychiatrists have never explained clinical depression solely in terms of decreased serotonin levels or a specific neurotransmitter” and that just as with the selective serotonin reuptake inhibitors, the so-called SSRIs, like Prozac, “many drugs in clinical medicine act through unknown or multiple mechanisms. And that doesn’t affect their safety, efficacy, or approval for medical use.” Doesn’t that contradict your views?
First of all, it is true that psychiatrists have always viewed depression as a bio-psycho-social phenomenon of which the biological is only a part. But there’s a problem. Given that there is a specific abnormality in the brain that can be addressed by a drug, then of course it makes sense to take that drug. Especially when you feel like other things like what’s going on in people’s lives should take a back seat and you need to focus on a problem in the brain. Then of course you have to correct it, if you can correct it. But this approach is misleading because to suggest or tell people that an abnormality has been found, that a serotonin abnormality has been found,
They’re also correct that many psychiatrists have been saying lately that it doesn’t matter how antidepressants work, and that those psychiatrists haven’t necessarily said that the drugs work by correcting an underlying chemical imbalance. I would like to say two things about this. First, the aspect of how antidepressants work is really important. Second, even if psychiatrists do not promote the idea of chemical imbalances as the cause of depression, and are reluctant to do so because the idea is so widespread and so many people believe it to be true, it is not enough just not to propagate them. You really have to tell people that you don’t support that idea, that there’s no evidence for it.
The most important piece of evidence would be a placebo-controlled study showing that taking an antidepressant is much better than doing nothing. In this regard , you say studies have shown that antidepressants are only “slightly better than placebo [or doing nothing] in terms of lowering depression scores over a few weeks. However, the difference is so small that it is not clear whether it is even noticeable. And there are indications that the small difference can be explained by an inadequate study design rather than by the effect of the drugs.” The already quoted psychiatrist Pies counters thisthat “there is ample evidence from placebo-controlled trials that serotonergic antidepressants are safe, effective, and can be used to treat acute major depressive episodes.”
This point is really important. So many people, in response to our work, have claimed that antidepressants work and have been shown to have important and significant benefits. I’d like to say that I don’t think that’s true. There are many large analyzes of placebo-controlled antidepressant trials that show that the difference between placebo and antidepressant is very small. That is undisputed. A very large study was recently published in the journal BMJ . This shows that the difference between the antidepressant and the placebo on the depression rating scale is less than two points, on a 52-point scale. Nobody believes that this difference is clinically important.
All of these studies relate only to a short observation period. And it may even be that the differences were measured too large because the method used was not entirely clean. In truth, not even the reported small difference between drug and placebo can exist.
The question is, moreover, to what this difference could be attributed. And I think there are two possible explanations for that. One is that participants in these studies often know whether they are taking the active drug or the placebo because they experience some side effects caused by the drug. You just feel a little different. As a result, the people taking the active drug in these studies could well have what you might call an “amplified placebo effect.” That could explain the difference between the placebo and the drug.
The other possible explanation is that antidepressants have a numbing effect on the emotions. This could result in a temporary reduction in the intensity of a person’s underlying sadness and depressive feelings, as well as a reduction in the intensity of positive feelings such as happiness or joy.
If, as you say, the science is clear on the point that there isn’t a solid study showing that taking an antidepressant is better than doing nothing or taking a placebo – then why are there still people like Pies who disagree and defend the official narrative?
Psychiatrists seem very reluctant to criticize antidepressant use. I think that’s because psychiatrists, and much of the society that follows them, believe that depression is a medical problem that can be treated with a medical solution. And that’s why they feel threatened by anything that fundamentally challenges this view.
How big is the influence of the pharmaceutical industry on psychiatry?
The pharmaceutical industry has a major impact on the public and on psychiatry. But let’s also not forget that psychiatrists had the idea of chemical imbalances before the pharmaceutical industry really got involved. The theory that depression is linked to low serotonin levels dates back to the 1960s and was put forward by a British psychiatrist. The pharmaceutical industry began promoting this idea of chemical imbalance in the 1990s. And it contributes to the fact that this idea is becoming more widespread in psychiatry. And what it has really achieved is convincing the public that it is a credible theory that has stood the test of time.
Is there a larger study in this field that is not funded by the pharmaceutical industry? Is there an independent science?
The pharmaceutical industry has had a massive impact on antidepressant research, as it conducts the vast majority of antidepressant studies. And we know that the studies of the pharmaceutical industry often “inflate” the effects of the drug that the pharmaceutical company is promoting. If the studies don’t show positive results for the company’s drug, they won’t be published, they’ll be “buried,” so to speak. And even in the studies that are published, there is often manipulation, “massage” – and the positive results are emphasized more than it should be considered from the point of view of reason.
That said, yes, the pharmaceutical industry definitely has a significant impact on antidepressant research.
I would like to quote the psychiatrist Pies again, who also states: “If serotonergic agents are not helpful, then antidepressants from other classes can be considered.” In contrast, the US journalist Robert Whitaker, who has been critical of today’s drug-fixated psychiatry for some time, told me in an interview in 2013 : “If you look at how the drug cocktails are prescribed, it’s all really a bit of rocket science” in a sense of hocus pocus. So, can switching to other medications be a solution – and if so, is there solid evidence that this approach is useful? Or is it all actually “witchcraft,” as Whitaker puts it?
We have shown that there is no evidence to support the idea that antidepressants can correct an underlying serotonin abnormality. And there is no better evidence regarding other abnormalities and other neurochemicals that could justify the use of antidepressants. All antidepressants are psychoactive substances in the sense that they alter normal mental states. For example, many antidepressants are reported to induce a state of emotional numbing, numbing both positive and negative feelings. And these effects, of course, affect the depression rating scales and other measures used in randomized trials.
All antidepressants have effects on people, they change the way people normally think and feel in one way or another, although with some compounds the effects are very subtle. All types of antidepressants have an effect on humans because they are not just “sluggish,” inactive substances. But we have no evidence that an SSRI antidepressant or any other drug targets the abnormality that underlies depression or that causes the symptoms of depression.
Sure, many people report feeling better after taking antidepressants. And many, many people actually feel better after taking antidepressants. However, we also know that many people also feel better after taking a placebo. We know that most of the effect of an antidepressant is undoubtedly a placebo effect. The influence of people’s expectations and the fact that they are offered hope and support is enormous. This has a significant impact on how people feel.
They also say that “it is not taken for granted that manipulating the brain with drugs is the most sensible level to deal with emotions” and that it is tantamount to “trying to solder a hard drive to fix a software problem. » It sounds as if you want to criticize the mechanistic world view that dominates the “modern” world and to which René Descartes contributed significantly. The 17th-century French philosopher saw the body of living beings as a kind of machine. Are you saying that the processes in the body are too complex to be compared to a computer hard drive that can be repaired by soldering – and that this leaves far too little room for dealing with emotions or feelings?
We need our brains and also our bodies to think, to feel, to communicate, to do everything we do. But that doesn’t mean we can explain the nature of our thoughts and feelings by looking inside the brain. This is the wrong level to understand human behavior, human thinking and human feeling. This is not only my opinion, but also that of many other people who criticize this reductionist view because it reduces depression, happiness or love or one’s political views, one’s taste for books or music to events in the brain.
Many philosophers have also written that this view is nonsensical. These human traits like love and taste in music need to be understood in the context of the human world. They don’t make sense if you try to talk about them in terms of nerves and neurological events and activities.
Even experts like Pies concede that “it’s legitimate to debate whether antidepressants are effective when you take them long-term.” Going one step further , they state not only that it is “impossible to say that taking antidepressants or SSRIs is worthwhile,” but also that “it is not clear that these drugs do more good than harm.” What harm can they do?
This is a really important point. We definitely have no evidence that antidepressants reverse an underlying disorder. On the other hand, we know – and no one disputes this – that these are drugs that act on the brain. Yes, we even have to conclude that these drugs actually alter the normal state of the brain. They modify it, they change our normal brain state, our normal brain chemistry. And if you take a substance that changes your normal brain chemistry every day for weeks, months, or years, then you could be harming yourself. We know this because it is known that people who drink a lot of alcohol every day harm themselves and that people who use other fad drugs
We also know that long-term use of antidepressants can cause a range of harms related to the way they change the brain. For example, we now know that people become physically dependent on antidepressants and as a result, when they try to stop taking them, they can sometimes experience really severe, debilitating, and protracted withdrawal symptoms. We also know that antidepressants cause sexual dysfunction. They even do that in the short term. It is a very common side effect that is very well known.
And it’s becoming increasingly clear that some people continue to experience sexual side effects even after they stop taking the antidepressant. This suggests that the antidepressant has changed sexuality. And that assumes the antidepressant has altered the brain in some way, in a harmful way.
I am not saying that this is necessarily a permanent condition. We haven’t observed this effect long enough to know if it’s permanent or if it might go away over time. But it’s definitely something that occurs in some people who have been taking these drugs for a long time.
Antidepressants have also been cited as a cause of violent crime and even murder by experts like Peter Breggin. What do you make of it?
There is evidence that antidepressants may lead to more suicidal behavior in younger people than in people receiving a placebo. This is based on randomized controlled trials. In addition, young people taking antidepressants are at greater risk of aggression than young people taking placebo in these studies. The risk is very low in these studies, and only in younger people. Part of the explanation for reporting the risk as so low is that these studies attempt to select people who have no or a minimal number of risk factors. So in real life, the risk might actually be a bit higher.
I also think that this risk is related to the fact that antidepressants seem to have arousing effects, especially in younger people. While we don’t know why this is more common among young people than older people, it appears to be the case. So in younger people, antidepressants can make them more restless, tense, irritable, and emotionally unstable. This effect appears to be related to impulsive behaviors, which can also occasionally lead to self-injurious, suicidal, and aggressive behavior.
They also say that “only a minority of drugs target the root cause of a disease.” So what would a treatment for mental illness like depression that addresses these “underlying causes of a disease” look like?
Medications may not treat the root cause of the disease. In fact, most of them don’t, but they do target the underlying biological pathways that produce the symptoms. Thus, even painkillers that are clearly only symptomatic treatment target the underlying neurological mechanisms that cause pain. Psychotropic drugs work differently. They don’t target the underlying processes. They bring about changes in normal mental states – and these changes then overlay the person’s emotional problem.
At present we do not know of any underlying neurological processes for any type of mental disorder that could be addressed by biological treatment. And I’m not sure we’ll be able to do that because, as I said, the way we look at mental disorders is unduly reductionist. This point of view tries to find the problem in the brain instead of looking at it on the level of the human being and the human being in his world.
What does this mean for antidepressant use? For example, as far as I understand, the psychiatrist Peter Breggin tries to avoid the use of antidepressants as a matter of principle. How about you?
When people feel depressed and take medication, I think it should be viewed in the same way as consuming alcohol. As you take it, your mental state changes – and then you stop using it and your mental state returns. And if you’ve been taking the drug for a long time, you may have other complications as well. So in general I think drugs should be avoided, especially in the long run. I think there are some crisis situations where a drug like benzodiazepine that relaxes people and helps them fall asleep can be helpful for a few days.
But the most important thing for me is to really inform people so that they can form their own opinions about the use of medicines. There may be people who want to try to change their normal mental state, feel different, and numb their feelings by taking antidepressants. But then we have to have a debate about whether we think this is appropriate medical treatment for emotional problems, whether we should support it or not. But first, we need to be really honest about what happens when people take medication to deal with their emotional problems, and involve patients in this debate.
What is the alternative to medication then? For example psychotherapy? Or what about exercise, diet and toxins like heavy metals? The book “Nutrition and Psyche” , for example, the first edition of which dates back to the 1980s, deals with the influence of nutrition, but also of industrial toxins on mental well-being. Or let ‘s take the study “Diet, exercise, lifestyle, and mental distress among young and mature men and women” published in 2021, which came to the following conclusion comes: “Our results support the need to adapt dietary and lifestyle recommendations to improve psychological well-being.”
The first thing I would say is that we need an approach that looks at mental health problems differently. So instead of looking at them as diagnoses or disorders that are common to everyone affected, we need to see people as individuals with their own problems. And every person with depression reacts to a different situation.
It’s about understanding why someone is depressed and the circumstances that made them depressed. That’s the most important thing to help someone. So each person with depression needs a different solution depending on what made them depressed. If you’re depressed because of relationship issues, maybe you need relationship counseling, maybe you need a dating app. Or maybe you just need a friend to have a cup of tea with and cry your heart out with. Again, it will be different for everyone.
So that’s the first point: everyone has mental health issues for different reasons. And it’s the reasons people have these issues that we need to focus on, rather than giving people blanket treatments. That being said, there are some worthwhile things people can do to improve their emotional and mental resilience. This definitely includes movement. Exercise has a very positive effect on mood and helps to reduce anxiety. So I think exercise is very important for people. The same applies to a healthy, balanced diet and taking care of your own body. Getting enough sleep is another very important factor in overall mental well-being.
I think all of these things are important. I’m not sure if I want to go into specific diets or supplements or anything like that. But I think it definitely helps to take care of yourself and exercise a lot.
What should those affected do then? Are there actually many therapists who do not follow a medication-fixed approach and would at least be willing not to take this approach if the patient wishes? Or do 99.9 percent of psychiatrists follow the drug-fixated path?
Most people get antidepressants prescribed by their family doctor rather than a psychiatrist. And I know that GPs are trying to offer people alternatives. So I think we need a combination: One, a public information campaign to educate people that this idea of chemical imbalance is wrong, unsupported, and that we don’t know that antidepressants work that way and they do something can do very different things, which are some disturbing things. Second, we need to educate, encourage and support doctors to offer patients alternatives to medication, such as membership at the local gym.
In the UK, there is some degree of such ‘social prescribing’, where doctors can prescribe people to go to the gym or recommend other social activities instead of prescribing medicines. And we have to support and encourage that.
What made you become critical – and is it difficult to be critical in your job? Do you get a lot of support?
During my training I developed a critical attitude towards psychiatry and traditional medical solutions to mental health problems. Because while other people seemed to have the feeling that psychiatric drugs work like antidepressants, I couldn’t see that. Sure, some people were better off with them, others worse off. But when people got better, there seemed to be another explanation. In my opinion, it didn’t necessarily have anything to do with the drug. So I wasn’t convinced. I became interested in psychotropic drugs and studied the literature closely. In doing so, I realized that there are a lot of methodological and conceptual problems in research into psychotropic drugs and psychiatric disorders.
I was also aware that some of my fellow psychiatrists shared my concerns about the dominant biomedical approach to mental health issues. For this reason I started a small group called the Critical Psychiatry Network . It still exists and is made up of psychiatrists who are skeptical of the biomedical model and the dominance of the pharmaceutical industry and drug-centric approaches to mental health problems.
What about the profession you work in – how does it react to your views? And are you just a small group, are you the exception?
We are a minority. And probably most of the leaders in our profession are people who are interested in biological psychiatry and have done biological research and worked with the pharmaceutical industry. But there are also some social psychiatrists who are more concerned with the social causes of mental illness and also with social treatments and the design of our service. And certainly there are many social psychiatrists in Britain…
… but are you being attacked or put under pressure by colleagues or others?
There are, without question, social psychiatrists and people like me. But I would say that there is still a great deal of resistance in psychiatry, particularly towards those who question the basis of drugs that are so commonly used, such as antidepressants. Yes, I have been criticized for being appropriately critical and trying to get factual information about how the way serotonin research is done affects our understanding of antidepressant use.
I have a feeling that the profession would prefer that this issue not be discussed in public and people not educated on the fact that antidepressants are mind-altering and brain-altering drugs that can have harmful effects if taken for long periods of time be taken.
If we take a quick look into the future, are you confident that this will change or what do you think?
Oh God! I think there are a lot of people today, especially when I talk to people in the US, who are totally convinced that mental health problems are brain problems and that we’re only treating the brain and the right drug or drugs need to find the right kind of biological intervention. This attitude has become deeply rooted in the public consciousness in recent decades. So I don’t think that’s going to change overnight. On the other hand, there are also a significant number of people who question this idea. And I think and I hope that after the publication of our paper and because of conversations like the one we’re having right now and the
Thank you Joanna for this interview.
Thank you Torsten.
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